Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
  • A61L31/00—Materials for other surgical articles, e.g. stents, stent-grafts, shunts, surgical drapes, guide wires, materials for adhesion prevention, occluding devices, surgical gloves, tissue fixation devices
  • A61L31/14—Materials characterised by their function or physical properties, e.g. injectable or lubricating compositions, shape-memory materials, surface modified materials
  • A61L31/16—Biologically active materials, e.g. therapeutic substances
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P35/00—Antineoplastic agents
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P37/00—Drugs for immunological or allergic disorders
  • A61P37/02—Immunomodulators
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P9/00—Drugs for disorders of the cardiovascular system
  • A61P9/10—Drugs for disorders of the cardiovascular system for treating ischaemic or atherosclerotic diseases, e.g. antianginal drugs, coronary vasodilators, drugs for myocardial infarction, retinopathy, cerebrovascula insufficiency, renal arteriosclerosis
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
  • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
  • A61F2/82—Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
  • A61F2/86—Stents in a form characterised by the wire-like elements; Stents in the form characterised by a net-like or mesh-like structure
  • A61F2/90—Stents in a form characterised by the wire-like elements; Stents in the form characterised by a net-like or mesh-like structure characterised by a net-like or mesh-like structure
  • A61F2/91—Stents in a form characterised by the wire-like elements; Stents in the form characterised by a net-like or mesh-like structure characterised by a net-like or mesh-like structure made from perforated sheet material or tubes, e.g. perforated by laser cuts or etched holes
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
  • A61F2250/00—Special features of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof
  • A61F2250/0058—Additional features; Implant or prostheses properties not otherwise provided for
  • A61F2250/0067—Means for introducing or releasing pharmaceutical products into the body
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
  • A61L2300/00—Biologically active materials used in bandages, wound dressings, absorbent pads or medical devices
  • A61L2300/40—Biologically active materials used in bandages, wound dressings, absorbent pads or medical devices characterised by a specific therapeutic activity or mode of action
  • A61L2300/416—Anti-neoplastic or anti-proliferative or anti-restenosis or anti-angiogenic agents, e.g. paclitaxel, sirolimus
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
  • A61L2300/00—Biologically active materials used in bandages, wound dressings, absorbent pads or medical devices
  • A61L2300/40—Biologically active materials used in bandages, wound dressings, absorbent pads or medical devices characterised by a specific therapeutic activity or mode of action
  • A61L2300/45—Mixtures of two or more drugs, e.g. synergistic mixtures

Definitions

• the invention relates to novel chemical compounds having immunomodulatory activity and/or anti-restenotic activity and synthetic intermediates useful for the preparation of the novel compounds, and in particular to macrolide immunomodulators. More particularly, the invention relates to semisynthetic analogs of rapamycin, means for their preparation, pharmaceutical compositions containing such compounds, and methods of treatment employing the same.
• cyclosporine (cyclosporin A) has found wide use since its introduction in the fields of organ transplantation and immunomodulation, and has brought about a significant increase in the success rate for transplantation procedures.
• macrocyclic compounds having potent immunomodulatory activity have been discovered.
• Okuhara et al. in European Patent Application No. 184,162, published June 11 , 1986, disclose a number of macrocyclic compounds isolated from the genus Streptomyces, including the immunosuppressant FK-506, a 23-membered macrocyclic lactone, which was isolated from a strain of S. tsukubaensis.
• FR-900520 and FR-900523 which differ from FK-506 in their alkyl substituent at C-21 , have been isolated from S. hygroscopicus yakushimnaensis.
• Unsatisfactory side-effects associated with cyclosporine and FK-506 such as nephrotoxicity, have led to a continued search for immunosuppressant compounds having improved efficacy and safety, including an immunosuppressive agent which is effective topically, but ineffective systemically (U.S. Patent No. 5,457,111 ).
• Rapamycin is a macrocyclic triene antibiotic produced by Streptomyces hygroscopic ⁇ s, which was found to have antifungal activity, particularly against Candida albicans, both in vitro and in vivo (C. Vezina et al., J. Antibiot. 1975, 28, 721; S. N. Sehgal et al., J. Antibiot. 1975, 28, 727; H. A. Baker et al., J. Antibiot. 1978, 31, 539; U.S. Patent No. 3,929,992; and U.S. Patent No. 3,993,749).
• Rapamycin alone (U.S. Patent No. 4,885,171 ) or in combination with picibanil (U.S. Patent No. 4,401,653) has been shown to have antitumor activity.
• rapamycin was also shown to be effective as an immunosuppressant in the experimental allergic encephalomyelitis model, a model for multiple sclerosis; in the adjuvant arthritis model, a model for rheumatoid arthritis; and was shown to effectively inhibit the formation of IgE- like antibodies (R. Martel et al., Can. J. Physiol. Pharmacol., 1977, 55, 48).
• Rapamycin has been shown to reduce neointimal proliferation in animal models, and to reduce the rate of restenosis in humans. Evidence has been published showing that rapamycin also exhibits an anti-inflammatory effect, a characteristic which supported its selection as an agent for the treatment of rheumatoid arthritis. Because both cell proliferation and inflammation are thought to be causative factors in the formation of restenotic lesions after balloon angioplasty and stent placement, rapamycin and analogs thereof have been proposed for the prevention of restenosis.
• rapamycin Numerous chemical modifications of rapamycin have been attempted. These include the preparation of mono- and di-ester derivatives of rapamycin (WO 92/05179), 27-oximes of rapamycin (EPO 467606); 42-oxo analog of rapamycin (U.S. Patent No. 5,023,262); bicyclic rapamycins (U.S. Patent No. 5,120,725); rapamycin dimers (U.S. Patent No. 5,120,727); silyl ethers of rapamycin (U.S. Patent No. 5,120,842); and arylsulfonates and sulfamates (U.S. Patent No. 5,177, 203).
• Rapamycin was recently synthesized in its naturally occurring enantiomeric form (K. C. Nicolaou et al., J. Am. Chem. Soc, 1993, 115, 4419-4420; D. Romo et al., J. Am. Chem. Soc, 1993, 115, 7906- 7907; C. Hayward, J. Am. Chem. Soc, 1993, 115, 9345-9346.
• paclitaxel A complex alkaloid extracted from the Pacific Yew, Taxus brevifolia, paclitaxel stabilizes components of the cell skeleton (tubulin, the building blocks of microtubules) that are critical in cell division, thus preventing cell proliferation .
• PTCA Percutaneous transluminal coronary angioplasty
• stents were introduced to maintain vessel patency after angioplasty. Stenting is involved in 90% of the angioplasties performed today. Before the introduction of stents, the rate of restenosis ranged from 30-50% of the patients who were treated with balloon angioplasty. Introduction of stenting resulted in further improvements in outcomes, with restenosis rates of 1530%. Following stenting, the restenosis lesion is caused primarily by neointimal hyperplasia, which is distinctly different from atherosclerotic disease both in time-course and in histopathologic appearance. Restenosis is a healing process of damaged coronary arterial walls, with neointimal tissue impinging significantly on the vessel lumen. Vascular brachytherapy appears to be efficacious against in-stent restenosis lesions. Radiation, however, has limitations of practicality and expense, and lingering questions about safety and durability.
• Figure 2 is a side view in elevation showing a stent suitable for use in this invention.
• Figure 3A is a cross-sectional view of a vessel segment in which was placed a stent coated with a polymer only.
• Figure 3B is a cross-sectional view of a vessel segment in which was placed a stent coated with a polymer plus drug.
• Figure 4 shows on a linear scale mean blood-concentration -time plot for single escalating i.v. doses of zotarolimus in humans.
• Figure 5 shows on a log-linear scale mean blood concentration-time plots, following single escalating i.v. doses of zotarolimus in humans.
• Figure 6 shows dose proportionality of zotarolimus C max and AUC parameters following single escalating intravenous doses in humans.
• Figure 7 shows mean blood concentration-time plots of zotarolimus following multiple intravenous doses in humans.
• Figure 8 shows mean zotarolimus blood concentration-time profiles for 200, 400 and 800 ⁇ g QD (daily) dose groups on Day 1 (Figure 8a), Day 14 ( Figure 8b), and Days 1-14 (Figure 8c).
• Figure 9 shows observed zotarolimus concentration-time data over days 1 through 14 for 800 ⁇ g QD dose group.
• Figures 10 and 11 are graphs showing effects of zotarolimus, dexamethasone and paclitaxel on LPS-stimulated MCP-1 , IL-6 and TNF- ⁇ production by human monocytes in vitro.
• Figure 12 is a graph showing the attenuation of the anti-proliferative activity of zotarolimus in the presence of tacrolimus, shows that tacrolimus blocks the anti-proliferative activity of zotarolimus in smooth muscle cells in vitro.
• Figure 13 is a graph of anti-proliferative activity of zotarolimus alone, dexamethasone alone and zotarolimus/dexamethasone combination in human coronary artery smooth muscle cells and endothelial cells.
• Figure 14 shows isobolograms of the anti-proliferative activity of a zotarolimus/dexamethasone combination in human coronary artery smooth muscle cells.
• Figure 15 is a graph of the combination index activity of the antiproliferative activity of several zotarolimus/dexamethasone combinations in human coronary artery smooth muscle cells.
• Figures 16 and 17 are graphs of accelerated elution rates from stents loaded with zotarolimus or dexamethasone.
• Figure 18 is a graph showing the elution rates of zotarolimus alone and in the presence of dexamethasone.
• Figure 19 is a bar graph showing neointimal areas in swine 28 days after implantation of zotarolimus/dexamethasone-eluting stents versus single drug-eluting stents and control stents.
• Figure 20 is a bar graph showing neointimal thicknesses in swine 28 days after implantation of zotarolimus/dexamethasone-eluting stents versus single drug-eluting stents and control stents.
• Figure 21 is a bar graph showing percent area stenosis in swine 28 days after implantation of zotarolimus/dexamethasone-eluting stents versus single drug-eluting stents and control stents.
• Figure 22 is a bar graph comparing neointimal area measurements (30% overstretch) from two swine studies after implantation of zotarolimus/dexamethasone-eluting stents versus single drug-eluting stents and control stents.
• Figure 23 is a bar graph comparing percent area stenosis (30% overstretch) from two swine studies after implantation of zotarolimus/dexamethasone-eluting stents versus single drug-eluting stents and control stent.
• Figure 24 is a photomicrograph showing the average responses in the two swine studies after implantation of zotarolimus/dexamethasone-eluting stents.
• Figures 24a-e show micrographs of cross-sections of representative blood vessels from a swine study, representing average neointimal areas for each group.
• Figure 24a TriMaxxTM, stent; 24b, ZoMaxxTM, stent; 24c, Cypher® stent; 24d, Taxus® stent; 24e, zotarolimus: paclitaxel, 10 ⁇ g/mm:1 ⁇ g/mm stent.
• the invention in another aspect of the invention, relates to a system for providing controlled release delivery of drugs for treatment or inhibition of neointimal hyperplasia in a blood vessel lumen, including a composition having a therapeutic amount of a first drug and a therapeutic amount of a second drug, wherein the first drug includes at least one olimus drug and their its salts, esters, prodrugs and derivatives thereof; and wherein the first drug is therapeutically effective and, in the presence of the therapeutic amount of the second drug, complements activity of the second drug and wherein the second drug is therapeutically effective and, in the presence of the therapeutic amount of the first drug, complements activity of the first drug.
• the invention relates to a pharmaceutical composition for reducing neointimal hyperplasia administered locally, including at least one olimus drug and at least one glucocorticosteriod, wherein the olimus drug(s) and the glucocorticosteriod(s) are in a ratio of between about 10:1 to about 1 :10.
• embodiments of the invention are directed to a drug delivery system that has a supporting structure including at least one pharmaceutically acceptable carrier or excipient, and a therapeutic composition having zotarolimus and dexamethasone or derivatives, prodrugs, or salts thereof, wherein the formation of neointimal hyperplasia is reduced when the system is implanted in a lumen of a blood vessel of a subject when compared to a control system.
• the drug delivery system can include a stent, and can include a third — or more — drugs or other therapeutic substances, including biologicals.
• therapeutic substances include, but not limited to, antiproliferative agents, anti-platelet agents, steroidal and non-steroidal antiinflammatory agents, anti-thrombotic agents and thrombolytic agents.
• the subject can be mammalians including, but not limited to, humans and swine.
• Another object of embodiments of the invention is to provide synthetic processes for the preparation of such compounds from starting materials obtained by fermentation, as well as chemical intermediates useful in such synthetic processes.
• a further object of embodiments of the invention is to provide pharmaceutical compositions containing, as an active ingredient, at least one of the above compounds.
• Yet another object of embodiments of the invention is to provide a method of treating a variety of disease states, including restenosis, post- transplant tissue rejection, immune and autoimmune dysfunction, fungal growth, and cancer.
• a medical device comprising a supporting structure having a coating on at least one portion of the surface thereof, the coating including a therapeutic substance, such as, for example, a drug.
• Supporting structures for the medical devices that are suitable for use in this invention include, but are not limited to, coronary stents, peripheral stents, catheters, arterio-venous grafts, by-pass grafts, and drug delivery balloons used in the vasculature including angioplasty balloons.
• Drugs that are suitable for use in this invention include, but are not limited to,
• zotarolimus or a pharmaceutically acceptable salt or prodrug thereof, (hereinafter alternatively referred to as zotarolimus, as well as A-179578), and
• A-94507 a pharmaceutically acceptable salt or prodrug thereof, (hereinafter alternatively referred to as A-94507).
• the embodiments of the invention relates to the safe and effective local delivery of drug combinations including zotarolimus and dexamethasone.
• the drug combinations offer improvements in safety and efficacy versus single drug eluting stents, including those found in current clinical practice (Taxus ® and Cypher ® ).
• the embodiments of the invention provide methods and devices to safely and effectively further reduce neointimal area, neointimal thickness and percent area stenosis associated with local delivery devices delivering drug combinations.
• zotarolimus/dexamethasone combinations have not been observed to adversely affect the activity of either of the drugs.
• the combinations have demonstrated improvements in safety and efficacy versus single drug eluting stents, such as Taxus ® and Cypher ® .
• Coatings that are suitable for use in embodiments of the invention include, but are not limited to, polymeric coatings that comprise any polymeric material in which the therapeutic agents may be effectively dispersed.
• the coating can be hydrophilic, hydrophobic, biodegradable, or non-biodegradable. This medical device releases drugs at an appropriate rate to effectively reduce restenosis in vasculature.
• the direct coronary delivery of a drug including zotarolimus is expected to reduce the rate of restenosis to a level of about less than 15%.
• the term "associated with,” as used herein, refers to compounds which can be in many forms including, but not limited to, mixed, unmixed, microspheres, mixed with the coatings, mixed with the support structure.
• One skilled in the art would appreciate the variations of interactions between drugs, coatings/drugs, and drugs/coatings/support structures.
• the term "complementary” as used herein refers to the behavior exhibited by at least two drugs in combination where their respective pharmaceutical activities benefit from the combination by; in some instances having additive activity; in some instances having separate, but beneficial activities aiding in the overall desired pharmacological effect in mammals; and where the combination drugs do not actively reduce each other's biological activity.
• prodrug refers to compounds which are rapidly transformed in vivo to the parent compound of the above formula, for example, by hydrolysis in blood.
• a thorough discussion is provided by T. Higuchi and V. Stella, "Pro-drugs as Novel Delivery systems,” Vol. 14 of the A. C. S. Symposium Series, and in Edward B. Roche, ed., "Bioreversible Carriers in Drug Design,” American Pharmaceutical Association and Pergamon Press, 1987, both of which are incorporated herein by reference.
• prodrugs refers to those prodrugs of the compounds in embodiments of the invention which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of humans and lower mammals without undue toxicity, irritation, and allergic response, are commensurate with a reasonable benefit/risk ratio, and are effective for their intended use.
• Other embodiments include pharmaceutically acceptable prodrugs that are derivatized at the C-31 hydroxyl group.
• R R 1 C(O)R 2 R 3 ; R 1 C(S)R 2 R 3
• R 2 nothing, 0, N, S, various alkyl, alkenyl, alkynyl, heterocycles, aryl
• R 3 nothing, various alkyl, alkenyl, alkynyl, heterocycles, aryl
• Alkyl, alkenyl, alkynyl, heterocycles, aryl groups can be substituted or unsubstituted
• prodrug esters refers to any of several ester- forming groups that are hydrolyzed under physiological conditions.
• Examples of prodrug ester groups include acetyl, propionyl, pivaloyl, pivaloyloxymethyl, acetoxymethyl, phthalidyl, methoxymethyl, indanyl, and the like, as well as ester groups derived from the coupling of naturally or unnaturally-occurring amino acids to the C-31 hydroxyl group of compounds of embodiments of the invention.
• support structure means a framework that is capable of including or supporting a pharmaceutically acceptable carrier or excipient, which carrier or excipient may include one or more therapeutic agents or substances, e.g., one or more drugs and/or other compounds.
• the supporting structure is typically formed of metal or a polymeric material.
• Suitable supporting structures formed of polymeric materials, including biodegradable polymers, capable of including the therapeutic agents or substances include, without limitation, those disclosed in U.S. Patent Nos. 6,413,272 and 5,527,337, which are incorporated herein by reference.
• Subject means a vertebrate including, but not limited to mammals, including a monkey, dog, cat, rabbit, cow, pig, goat, sheep, horse, rat, mouse, guinea pig, and human.
• Therapeutic substance means any substance that when administered to a subject appropriately at appropriate doses, has a beneficial effect on the subject.
• the compounds of the invention possess immunomodulatory activity in mammals (including humans).
• immunosuppressants the compounds of embodiments of the invention are useful for the treatment and prevention of immune- mediated diseases including the resistance by transplantation of organs or tissue including heart, kidney, liver, medulla ossium, skin, cornea, lung, pancreas, intestinum ***, limb, muscle, nerves, duodenum, small-bowel, pancreatic-islet-cell, and the like; graft- versus-host diseases brought about by medulla ossium transplantation; autoimmune diseases including rheumatoid arthritis, systemic lupus erythematosus, Hashimoto's thyroiditis, multiple sclerosis, myasthenia gravis, Type I diabetes, uveitis, allergic encephalomyelitis, glomerulonephritis, and the like.
• Further uses include the treatment and prophylaxis of inflammatory and hyperproliferative skin diseases and cutaneous manifestations of immunologically-mediated illnesses, including psoriasis, atopic dermatitis, contact dermatitis and further eczematous dermatitises, seborrhoeis dermatitis, lichen planus, pemphigus, bullous pemphigoid, epidermolysis bullosa, urticaria, angioedemas, vasculitides, erythemas, cutaneous eosinophilias, lupus erythematosus, acne and alopecia areata; various eye diseases (autoimmune and otherwise) including keratoconjunctivitis, vernal conjunctivitis, uveitis associated with Behcet's disease, keratitis, herpetic keratitis, conical cornea, dystrophia epithelialis corneae, corneal leukoma, and o
• reversible obstructive airway disease including asthma (for example, bronchial asthma, allergic asthma, intrinsic asthma, extrinsic asthma and dust asthma), particularly chronic or inveterate asthma (for example, late asthma and airway hyper-responsiveness), bronchitis, allergic rhinitis, and the like are targeted by compounds of this invention.
• asthma for example, bronchial asthma, allergic asthma, intrinsic asthma, extrinsic asthma and dust asthma
• chronic or inveterate asthma for example, late asthma and airway hyper-responsiveness
• bronchitis allergic rhinitis
• Inflammation of mucosa and blood vessels including gastric ulcers, vascular damage caused by ischemic diseases and thrombosis.
• hyperproliferative vascular diseases including intimal smooth muscle cell hyperplasia, restenosis and vascular occlusion, particularly following biologically- or mechanically- mediated vascular injury, could be treated or prevented by the compounds of the invention.
• the compounds or drugs described herein can be applied to stents that have been coated with a polymeric compound. Incorporation of the compound or drug into the polymeric coating of the stent can be carried out by dipping the polymer-coated stent into a solution including the compound or drug for a sufficient period of time (such as, for example, five minutes) and then drying the coated stent, such as, for example, by means of air drying for a sufficient period of time (such as, for example, 30 minutes). Other methods of applying therapeutic substances, including spraying, can be used. The polymer-coated stent including the compound or drug can then be delivered to the coronary vessel by deployment from a balloon catheter or via a self expanding stent.
• stents In addition to stents, other devices that can be used to introduce the drugs of this invention to the vasculature include, but are not limited to grafts, catheters, and balloons.
• other compounds or drugs that can be used in lieu of the drugs of this invention include, but are not limited to, A-94507 and SDZ RAD (a.k.a. Everolimus).
• the compounds described herein for use in polymer-coated stents can be used in combination with other pharmacological agents.
• the pharmacological agents that would be, in combination with the compounds of this invention, most effective in preventing restenosis can be classified into the categories of anti-proliferative agents, anti-platelet agents, anti-inflammatory agents, anti-thrombotic agents, and thrombolytic agents. These classes can be further sub-divided.
• anti-proliferative agents can be anti-mitotic.
• Anti-mitotic agents inhibit or affect cell division, whereby processes normally involved in cell division do not take place.
• One sub-class of anti-mitotic agents includes vinca alkaloids.
• vinca alkaloids include, but are not limited to, vincristine, paclitaxel, etoposide, nocodazole, indirubin, and anthracycline derivatives, such as, for example, daunorubicin, daunomycin, and plicamycin.
• anti-mitotic agents include anti-mitotic alkylating agents, such as, for example, tauromustine, bofumustine, and fotemustine, and anti-mitotic metabolites, such as, for example, methotrexate, fluorouracil, 5-bromodeoxyuridine, 6-azacytidine, and cytarabine.
• Anti-mitotic alkylating agents affect cell division by covalently modifying DNA, RNA, or proteins, thereby inhibiting DNA replication, RNA transcription, RNA translation, protein synthesis, or combinations of the foregoing.
• an anti-mitotic agent includes, but is not limited to, paclitaxel.
• paclitaxel includes the alkaloid itself and naturally occurring forms and derivatives thereof, as well as synthetic and semi-synthetic forms thereof.
• Anti-platelet agents are therapeutic entities that act by (1 ) inhibiting adhesion of platelets to a surface, typically a thrombogenic surface, (2) inhibiting aggregation of platelets, (3) inhibiting activation of platelets, or (4) combinations of the foregoing.
• Activation of platelets is a process whereby platelets are converted from a quiescent, resting state to one in which platelets undergo a number of morphologic changes induced by contact with a thrombogenic surface. These changes include changes in the shape of the platelets, accompanied by the formation of pseudopods, binding to membrane receptors, and secretion of small molecules and proteins, such as, for example, ADP and platelet factor 4.
• Anti-platelet agents that act as inhibitors of adhesion of platelets include, but are not limited to, eptifibatide, tirofiban, RGD (Arg-Gly- Asp)-based peptides that inhibit binding to gpllbllla or ⁇ v ⁇ 3, antibodies that block binding to gpllalllb or ⁇ v ⁇ 3, anti-P-selectin antibodies, anti-E-selectin antibodies, compounds that block P-selectin or E-selectin binding to their respective ligands, saratin, and anti-von Willebrand factor antibodies.
• Agents that inhibit ADP-mediated platelet aggregation include, but are not limited to, disagregin and cilostazol.
• Anti-inflammatory agents can also be used. Examples of these include, but are not limited to, prednisone, dexamethasone, hydrocortisone, estradiol, triamcinolone, mometasone, fluticasone, clobetasol, and non-steroidal antiinflammatories, such as, for example, acetaminophen, ibuprofen, naproxen, adalimumab and sulindac.
• the arachidonate metabolite prostacyclin or prostacyclin analogs is an example of a vasoactive antiproliferative.
• agents include those that block cytokine activity or inhibit binding of cytokines or chemokines to the cognate receptors to inhibit proinflammatory signals transduced by the cytokines or the chemokines.
• Representative examples of these agents include, but are not limited to, anti- IL1 , anti-IL2, anti-IL3, anti-IL4, anti-IL8, anti-IL15, anti-IL18, anti-MCP1 , anti- CCR2, anti-GM-CSF, and anti-TNF antibodies.
• the second drug being a glucocorticosteriod including methylprednisolone, prednisolone, prednisone, triamcinolone, dexamethasone, mometasone, beclomethasone, ciclesonide, bedesonide, triamcinolone, clobetasol, flunisolide, loteprednol, budesonide, fluticasone, and their its salts, esters, prodrugs, and derivatives or any combination thereof.
• the second drug is a steroid hormone including an estradiol and salts, esters, prodrugs, and derivatives or any combination thereof.
• agents that can be used in combination with the compounds of this invention include anti-lipaedemic agents, such as, for example, fenofibrate, atorvastatin, fluvastatin, lovastatin, mevastatin, pitavastatin, pravastatin, rosuvastatin and simvastatin.
• Additional agents include matrix metalloproteinase inhibitors, such as, for example, batimistat, as well as antagonists of the endothelin-A receptor, such as, for example, darusentan, and antagonists of the ⁇ v ⁇ 3 integrin receptor.
• Anti-thrombotic agents include chemical and biological entities that can intervene at any stage in the coagulation pathway. Examples of specific entities include, but are not limited to, small molecules that inhibit the activity of factor Xa.
• heparinoid-type agents that can inhibit both FXa and thrombin, either directly or indirectly, such as, for example, heparins, heparan sulfate, low molecular weight heparins, such as, for example, the compound having the trademark Clivarin®, and synthetic oligosaccharides, such as, for example, the compound having the trademark Arixtra®.
• direct thrombin inhibitors such as, for example, melagatran, ximelagatran, argatroban, inogatran, and peptidomimetics of binding site of the Phe-Pro-Arg fibrinogen substrate for thrombin.
• factor VII ⁇ /lla inhibitors such as, for example, anti-factor VII ⁇ /lla antibodies, rNAPc2, and tissue factor pathway inhibitor (TFPI).
• Thrombolytic agents which may be defined as agents that help degrade thrombi (clots), can also be used as adjunctive agents, because the action of lysing a clot helps to disperse platelets trapped within the fibrin matrix of a thrombus.
• Representative examples of thrombolytic agents include, but are not limited to, urokinase or recombinant urokinase, pro-urokinase or recombinant pro-urokinase, tissue plasminogen activator or its recombinant form, and streptokinase.
• cytotoxic drugs such as, for example, apoptosis inducers, such as TGF, and topoisomerase inhibitors, including 10-hydroxycamptothecin, irinotecan, and doxorubicin.
• cytotoxic drugs such as, for example, apoptosis inducers, such as TGF, and topoisomerase inhibitors, including 10-hydroxycamptothecin, irinotecan, and doxorubicin.
• drugs that inhibit cell de- differentiation and cytostatic drugs are drugs that inhibit cell de- differentiation and cytostatic drugs.
• agents that can be used in combination with the compounds of this invention include anti-lipidemic agents, such as, for example, fenofibrate, matrix metalloproteinase inhibitors, such as, for example, batimistat, antagonists of the endothelin-A receptor, such as, for example, darusentan, and antagonists of the ⁇ v ⁇ 3 integrin receptor.
• anti-lipidemic agents such as, for example, fenofibrate, matrix metalloproteinase inhibitors, such as, for example, batimistat
• antagonists of the endothelin-A receptor such as, for example, darusentan
• antagonists of the ⁇ v ⁇ 3 integrin receptor such as, for example, darusentan
• Embodiments of the invention further include a third therapeutic drug or substance.
• a third therapeutic drug or substance includes, but are not limited to, anti-proliferative agents, anti-platelet agents, anti-inflammatory agents, anti-lipidemic agents, anti-thrombotic agents, thrombolytic agents, their salts, prodrugs, and derivatives or any combination thereof.
• a second drug and/or third therapeutic drug is a glucocorticosteriod it includes, but is not limited to, methylprednisolone, prednisolone, prednisone, triamcinolone, dexamethasone, mometasone, beclomethasone, ciclesonide, bedesonide, triamcinolone, clobetasol, flunisolide, loteprednol, budesonide, fluticasone, their salts, prodrugs, and derivatives or any combination thereof.
• a second drug and/or third therapeutic drug is a steroid hormone it includes, nut is not limited to, an estradiol and their salts, prodrugs, and derivatives or any combination thereof.
• a second drug and/or third therapeutic drug when a second drug and/or third therapeutic drug it can be small molecules and biologies that reduce inflammatory cytokine activity.
• a second drug and/or third therapeutic drug utilizes an anti-TNF ⁇ therapies it includes, but is not limited to, adalimumab, anti-MCP-1 therapies, CCR2 receptor antagonists, anti-IL-18 therapies, anti-IL-1 therapies, and their salts, prodrugs, and derivatives, or any combination thereof.
• a said second drug and/or third therapeutic drug utilizes an anti-proliferative agent it includes, but is not limited to, alkylating agents including cyclophosphamide, chlorambucil, busulfan, carmustine and lomustine, anti-metabolites including methotrexate, fluorouracil, cytarabine, mercaptopurine and pentostatin, vinca alkaloids including vinblastine and vincristine, antibiotics including doxorubicin, bleomycin and mitomycin, antiproliferatives including cisplatin, procarbazine, etoposide and teniposide, their salts, prodrugs, and derivatives, or any combination thereof.
• alkylating agents including cyclophosphamide, chlorambucil, busulfan, carmustine and lomustine
• anti-metabolites including methotrexate, fluorouracil, cytarabine, mercaptopurine and pentostatin, vin
• a second drug and/or third therapeutic drug utilizes an anti-platelet agent it includes, but is not limited to, glycoprotein IIB/IIIA inhibitors including abciximab, eptifibatide and tirofiban, adenosine reuptake inhibitors including dipyridamole, ADP inhibitors including clopidogrel and ticlopidine, cyclooxygenase inhibitors including acetylsalicylic acid, and phosphodiesterase inhibitors including cilostazol, their salts, prodrugs, and derivatives, or any combination thereof.
• glycoprotein IIB/IIIA inhibitors including abciximab, eptifibatide and tirofiban
• adenosine reuptake inhibitors including dipyridamole
• ADP inhibitors including clopidogrel and ticlopidine
• cyclooxygenase inhibitors including acetylsalicylic acid
• phosphodiesterase inhibitors including cilost
• a second drug and/or third therapeutic drug utilizes an anti-inflammatory agent it includes, but is not limited to, steroids including dexamethasone, hydrocortisone, fluticasone, clobetasol, mometasone and estradiol, and non-steroidal anti-inflammatory agents including acetaminophen, ibuprofen, naproxen, sulindac, piroxicam, mefanamic acid, those that inhibit binding of cytokines or chemokines to receptors to inhibit pro-inflammatory signals, including antibodies to IL-1 , IL-2, IL-8, IL-15, IL-18 and TNF, their salts, prodrugs, and derivatives, or any combination thereof.
• steroids including dexamethasone, hydrocortisone, fluticasone, clobetasol, mometasone and estradiol
• non-steroidal anti-inflammatory agents including acetaminophen, ibuprofen, naproxen, sulindac,
• heparins including unfractionated heparins and low-molecular weight heparins including clivarin, dalteparin, enoxaparin, nadroparin and tinzaparin, direct thrombin inhibitors including argatroban, hirudin, hirulog, hirugen, their salts, prodrugs, and derivatives, or any combination thereof.
• a second drug and/or third therapeutic drug utilizes an anti-lipidemic agent it includes, HMG CoA reductase inhibitors including mevastatin, lovastatin, simvastatin, pravastatin, fluvastatin, fibric acid derivatives including fenofibrate, clofibrate, gemfibrozil, lipid-lowering agents including nicotinic acid, probucol, their salts, prodrugs, and derivatives or any combination thereof.
• HMG CoA reductase inhibitors including mevastatin, lovastatin, simvastatin, pravastatin, fluvastatin, fibric acid derivatives including fenofibrate, clofibrate, gemfibrozil, lipid-lowering agents including nicotinic acid, probucol, their salts, prodrugs, and derivatives or any combination thereof.
• thrombolytic agents When a second drug and/or third therapeutic drug utilizes thrombolytic agents it includes, but is not limited to, streptokinase, urokinase, pro-urokinase, tissue plasminogen activators including alteplase, reteplase, tenectaplase, their salts, prodrugs, and derivatives, or any combination thereof.
• the coating can comprise any polymeric material in which the therapeutic agents, i.e., the drugs, are substantially soluble or effectively dispersed.
• the purpose of the coating is to serve as a controlled release vehicle for the therapeutic agent or as a reservoir for a therapeutic agent to be delivered at the site of a lesion.
• the coating can be polymeric and can further be hydrophilic, hydrophobic, biodegradable, or nonbiodegradable.
• the material for the polymeric coating can be selected from the group consisting of polycarboxylic acids, cellulosic polymers, gelatin, polyvinylpyrrolidone, maleic anhydride polymers, polyamides, polyvinyl alcohols, polyethylene oxides, glycosaminoglycans, polysaccharides, polyesters, polyurethanes, silicones, polyorthoesters, polyanhydrides, polycarbonates, polypropylenes, polylactic acids, polyglycolic acids, polycaprolactones, polyhydroxybutyrate valerates, polyacrylamides, polyethers, and mixtures and copolymers of the foregoing.
• Coatings prepared from polymeric dispersions including polyurethane dispersions (BAYHYDROL, etc.) and acrylic acid latex dispersions can also be used with the therapeutic agents of the invention.
• Biodegradable polymers that can be used in this invention include polymers including poly(L-lactic acid), poly(DL-lactic acid), polycaprolactone, poly(hydroxy butyrate), polyglycolide, poly(diaxanone), poly(hydroxy valerate), polyorthoester; copolymers including poly (lactide-co-glycolide), polyhydroxy (butyrate-co-valerate), polyglycolide-co-trimethylene carbonate; polyanhydrides; polyphosphoester; polyphosphoester-urethane; polyamino acids; polycyanoacrylates; biomolecules including fibrin, fibrinogen, cellulose, starch, collagen and hyaluronic acid; and mixtures of the foregoing.
• Biostable materials that are suitable for use in this invention include polymers including polyurethane, silicones, polyesters, polyolefins, polyamides, polycaprolactam, polyimide, polyvinyl chloride, polyvinyl methyl ether, polyvinyl alcohol, acrylic polymers and copolymers, polyacrylonitrile, polystyrene copolymers of vinyl monomers with olefins (including styrene acrylonitrile copolymers, ethylene methyl methacrylate copolymers, ethylene vinyl acetate), polyethers, rayons, cellulosics (including cellulose acetate, cellulose nitrate, cellulose propionate, etc.), parylene and derivatives thereof; and mixtures and copolymers of the foregoing.
• polymers including polyurethane, silicones, polyesters, polyolefins, polyamides, polycaprolactam, polyimide, polyvinyl chloride, polyvinyl methyl
• the polymers include, but are not limited to, poly(acrylates) such as poly(ethyl methacrylate), poly(n-propyl methacrylate), poly(isopropyl methacrylate), poly(isobutyl methacrylate), poly(sec-butyl methacrylate), poly(n-butyl methacrylate), poly(2-ethylhexyl methacrylate), poly(n-hexyl methacrylate), poly(cyclohexyl methacrylate), poly(n-hexyl methacrylate), poly(isobornyl methacrylate), and poly(trimethylcyclohexyl methacrylate), poly(methyl acrylate), poly(ethyl arylate), poly(n-propyl acrylate), poly(isopropyl acrylate), poly(n-butyl acrylate), poly(isobutyl acrylate), poly(sec- butyl acrylate), poly(acrylates) such as poly(e
• the polymers include, but are not limited to, poly(ester urethanes), poly(ether urethanes), poly(urea urethanes), poly(urethanes); silicones; fluorosilicones, poly(esters); poly(ethylene); poly(propylene); poly(olefins); copolymers of poly(isobutylene); triblock copolymers of styrene and isobutylene; triblock copolymers of styrene and ethylene/butylenes; triblock copolymers of styrene and butadiene; copolymers of ethylene-alphaolefin; vinyl halide polymers and copolymers such as polyvinyl chloride) and polyvinyl fluoride); poly(vinylidene halides) such as, for example, poly(vinylidene chloride) and poly(vinylidene fluoride); poly(vinylidene fluoride fluoride fluoride
• the polymers include, but are not limited to, poly(amides) such as Nylon 66 and poly(caprolactam); alkyd resins; poly(carbonates); poly(sulfone); poly(oxymethylenes); poly(imides); poly(ester amides); poly(ethers) including poly(alkylene glycols) such as, for example, poly(ethylene glycol) and polypropylene glycol); epoxy resins; rayon; rayon- triacetate; biomolecules such as, for example, fibrin, fibrinogen, starch, poly(amino acids); peptides, proteins, gelatin, chondroitin sulfate, dermatan sulfate (a copolymer of D-glucuronic acid or L-iduronic acid and N-acetyl-D- galactosamine), collagen, hyaluronic acid, and glycosaminoglycans; other polysaccharides such as, for example, poly(N-acetyl)
• Another polymer that can be used in this invention is poly(MPC w :LAM x :HPMA y :TSMA z ) where w, x, y, and z represent the molar ratios of monomers used in the feed for preparing the polymer and MPC represents the unit 2-methacryoyloxyethylphosphorylcholine, LMA represents the unit lauryl methacrylate, HPMA represents the unit 2-hydroxypropyl methacrylate, and TSMA represents the unit 3-trimethoxysilylpropyl methacrylate.
• the drug-impregnated stent can be used to maintain patency of a coronary artery previously occluded by thrombus and/or atherosclerotic plaque.
• the delivery of an anti-proliferative agent reduces the rate of in-stent restenosis.
• Polymers which can be used in this invention include zwitterionic polymers including phosphorylcholine units.
• Other treatable conditions include but are not limited to ischemic bowel diseases, inflammatory bowel diseases, necrotizing enterocolitis, intestinal inflammations/allergies including Coeliac diseases, proctitis, eosinophilic gastroenteritis, mastocytosis, Crohn's disease and ulcerative colitis; nervous diseases including multiple myositis, Guillain-Barre syndrome, Meniere's o disease, polyneuritis, multiple neuritis, mononeuritis and radiculopathy; endocrine diseases including hyperthyroidism and Basedow's disease; hematic diseases including pure red cell aplasia, aplastic anemia, hypoplastic anemia, idiopathic thrombocytopenic purpura, autoimmune hemolytic anemia, agranulocytosis, pernicious anemia, megaloblastic anemia and anerythroplasia; bone diseases including osteoporosis; respiratory diseases including sarcoidosis, fibroid lung and idiopathic intersti
• the compounds of the invention are useful for the treatment and prevention of hepatic disease including immunogenic diseases (for example, chronic autoimmune liver diseases including autoimmune hepatitis, primary biliary cirrhosis and sclerosing cholangitis), partial liver resection, acute liver necrosis (e.g., necrosis caused by toxin, viral hepatitis, shock or anoxia), B-virus hepatitis, non-A/non-B hepatitis, cirrhosis (including alcoholic cirrhosis) and hepatic failure including fulminant hepatic failure, late-onset hepatic failure and "acute-on-chronic" liver failure (acute liver failure on chronic liver diseases), and moreover are useful for various diseases because of their potentially useful activity in augmention of the primary chemotherapeutic, antiviral, anti-inflammatory, and cardiotonic effects of drugs the patient may already be taking.
• immunogenic diseases for example, chronic autoimmune liver diseases including autoimmune hepati
• Proliferative diseases include smooth muscle proliferation, systemic sclerosis, cirrhosis of the liver, adult respiratory distress syndrome, idiopathic cardiomyopathy, lupus erythematosus, diabetic retinopathy or other retinopathies, psoriasis, scleroderma, prostatic hyperplasia, cardiac hyperplasia, restenosis following arterial injury or other pathologic stenosis of blood vessels.
• these compounds antagonize cellular responses to several growth factors, and therefore possess antiangiogenic properties, making them useful agents to control or reverse the growth of certain tumors, as well as fibrotic diseases of the lung, liver, and kidney.
• Aqueous liquid compositions of embodiments of the invention are particularly useful for the treatment and prevention of various diseases of the eye including autoimmune diseases (including, for example, conical cornea, keratitis, dysophia epithelialis corneae, leukoma, Mooren's ulcer, sclevitis and Graves' ophthalmopathy) and rejection of corneal transplantation.
• autoimmune diseases including, for example, conical cornea, keratitis, dysophia epithelialis corneae, leukoma, Mooren's ulcer, sclevitis and Graves' ophthalmopathy
• a therapeutically effective amount of one of the compounds of the embodiments of the invention may be employed in pure form or, where such forms exist, in pharmaceutically acceptable salt, ester or prodrug form.
• the compound may be administered as a pharmaceutical composition including the compound of interest in combination with one or more pharmaceutically acceptable excipients.
• therapeutically effective amount means a sufficient amount of the compound to treat disorders, at a reasonable benefit/risk ratio applicable to any medical treatment. It will be understood, however, that the total daily usage of the compounds and compositions of the embodiments of the invention will be decided by the attending physician within the scope of sound medical judgment.
• the specific therapeutically effective dose level for any particular patient will depend upon a variety of factors including the disorder being treated and the severity of the disorder; activity of the specific compound employed; the specific composition employed; the age, body weight, general health, sex and diet of the patient; the time of administration, route of administration, and rate of excretion of the specific compound employed; the duration of the treatment; drugs used in combination or coincidental with the specific compound employed; and like factors well known in the medical arts. For example, it is well within the skill of the art to start doses of the compound at levels lower than required to achieve the desired therapeutic effect and to gradually increase the dosage until the desired effect is achieved.
• the total daily dose of the compounds in embodiments of this invention administered to a human or lower animal may range from about 0.01 to about 10 mg/kg/day.
• doses may be in the range of from about 0.001 to about 3 mg/kg/day.
• the daily dose that a patient will receive depends on the length of the stent.
• a 15 mm coronary stent may include a drug in an amount ranging from about 1 to about 600 micrograms and may deliver that drug over a time period ranging from several hours to several weeks.
• the effective daily dose may be divided into multiple doses for purposes of administration; consequently, single dose compositions may include such amounts or submultiples thereof to make up the daily dose.
• single dose compositions may include such amounts or submultiples thereof to make up the daily dose.
• One skilled in the art could use the invention for topical administration and doses would depend on the site of application.
• a stent delivering a zotarolimus/dexamethasone combination according to the invention can include 10 mcg/mm zotarolimus and 10 mcg/mm dexamethasone in a PC polymer layer with a 5 mcg/mm PC topcoat.
• Total drug:polymer ratio can be lower, however, e.g., 40:60 or less.
• Upper limits on the total amount of drug will depend on several factors, including miscibility of the selected drugs in the selected polymer, the stability of the drug/polymer mixture, e.g., compatibility with sterilization, and the physical properties of the mixture, e.g., flowability/processability, elasticity, brittleness, viscosity (does not web or bridge between stent struts), coating thickness that adds substantially to the stent profile or causes delamination or cracking or is difficult to crimp.
• Embodiments of the invention include stent struts spaced about 60-80 microns apart, suggesting an upper limit in thickness of the drug/polymer/polymer overcoat is about 30 microns; however, any stent size, strut size and spatial spacing, and/or stent construction can be utilized for drug delivery as described therein.
• the therapeutic amount of an olimus drug includes zotarolimus or everolimus and is at least 1 ⁇ g/mm stent.
• the second drug is a glucocorticosteriod. When the second drug is utilized in embodiments, this second drug is dexamethasone and the therapeutic amount is at least 0.5 ⁇ g/mm stent
• Overcoat thickness desirably should not unduly impede release kinetics of the drugs.
• the overcoat can also be loaded with one or more drugs, which can be the same or different than those in the underlying drug-loaded polymer layer.
• drugs useful in combinations for the invention will not adversely affect the desired activity of the other drug in the combination.
• the drugs proposed for use in the combination may be have complementary activities or mechanisms of action.
• one drug in the proposed combination should not inhibit the desired activity, e.g., anti-proliferative activity, of the other drug.
• drug cause or enhance the degradation of the other drug e.g., anti-proliferative activity
• a drug that might otherwise appear to be unsuitable because, for example, it degrades during sterilization can in fact be useful because of an interaction by another drug.
• dexamethasone which alone has been observed to degrade during EtO sterilization, can be used successfully in combination with zotarolimus, due to the hydrophobicity of zotarolimus.
• zotarolimus has been observed to reduce the elution rate of dexamethasone, as described in Applicants' co-pending U.S. Patent Application No. 10/796,423.
• compositions of embodiments of the invention comprise a compound and a pharmaceutically acceptable carrier or excipient, which may be administered orally, rectally, parenterally, intracisternally, intravaginally, intraperitoneal ⁇ , topically (as by powders, ointments, drops or transdermal patch), bucally, as an oral or nasal spray, or locally as in a stent placed within the vasculature as in a balloon catheter, or delivery to the pericardial space or into or onto the myocardium.
• pharmaceutically acceptable carrier means a non-toxic solid, semi-solid or liquid filler, diluent, encapsulating material or formulation auxiliary of any type.
• parenteral refers to all modes of administration other than oral, which include, but not limited to, intravenous, intraarterial, intramuscular, intraperitoneal, intrastemal, subcutaneous and intraarticular injection, infusion, transdermal, and placement, such as, for example, in the vasculature.
• compositions of this invention for parenteral injection comprise pharmaceutically acceptable sterile aqueous or nonaqueous solutions, dispersions, suspensions, nanoparticle suspensions, or emulsions as well as sterile powders for reconstitution into sterile injectable solutions or dispersions just prior to use.
• suitable aqueous and nonaqueous carriers, diluents, solvents or vehicles include water, ethanol, polyols (including glycerol, propylene glycol, polyethylene glycol, and the like), carboxymethylcellulose and suitable mixtures thereof, vegetable oils (including olive oil), and injectable organic esters including ethyl oleate.
• compositions may also include adjuvants such as, for example, preservatives, wetting agents, emulsifying agents, and dispersing agents.
• adjuvants such as, for example, preservatives, wetting agents, emulsifying agents, and dispersing agents.
• Prevention of the action of microorganisms may be ensured by the inclusion of various antibacterial and antifungal agents, for example, paraben, chlorobutanol, phenol sorbic acid, and the like. It may also be desirable to include isotonic agents including sugars, sodium chloride, and the like. Prolonged absorption of the injectable pharmaceutical form may be brought about by the inclusion of agents that delay absorption including aluminum monostearate and gelatin.
• Injectable depot forms are made by forming microencapsule matrices of the drug in biodegradable polymers including polylactide-polyglycolide. Depending upon the ratio of drug to polymer and the nature of the particular polymer employed, the rate of drug release can be controlled. Examples of other biodegradable polymers include poly(orthoesters) and poly(anhydrides). Depot injectable formulations are also prepared by entrapping the drug in liposomes or microemulsions which are compatible with body tissues.
• the injectable formulations can be sterilized, for example, by filtration through a bacterial-retaining filter, or by incorporating sterilizing agents in the form of sterile solid compositions which can be dissolved or dispersed in sterile water or other sterile injectable medium just prior to use.
• Solid dosage forms for oral administration include capsules, tablets, pills, powders, and granules.
• the active compound is mixed with at least one inert, pharmaceutically acceptable excipient or carrier including sodium citrate or dicalcium phosphate and/or a) fillers or extenders including starches, lactose, sucrose, glucose, mannitol, and silicic acid, b) binders such as, for example, carboxymethylcellulose, alginates, gelatin, polyvinylpyrrolidone, sucrose, and acacia, c) humectants including glycerol, d) disintegrating agents including agar-agar, calcium carbonate, potato or tapioca starch, alginic acid, certain silicates, and sodium carbonate, e) solution retarding agents including paraffin, f) absorption accelerators including quaternary ammonium compounds, g) wetting agents such as, for example, cetyl alcohol and glycerol
• compositions of a similar type may also be employed as fillers in soft, semi-solid and hard-filled gelatin capsules or liquid-filled capsules using such excipients as lactose or milk sugar as well as high molecular weight polyethylene glycols and the like.
• the solid dosage forms for oral administration can be prepared with coatings and shells including enteric coatings and other coatings well known in the pharmaceutical formulating art. They may optionally contain opacifying agents and can also be of a composition that they release the active ingredient(s) only, or preferentially, in a certain part of the intestinal tract, optionally, in a delayed manner.
• coatings and shells including enteric coatings and other coatings well known in the pharmaceutical formulating art. They may optionally contain opacifying agents and can also be of a composition that they release the active ingredient(s) only, or preferentially, in a certain part of the intestinal tract, optionally, in a delayed manner.
• Examples of embedding compositions that can be used include polymeric substances and waxes. Those embedding compositions including a drug can be placed on medical devices, including stents, grafts, catheters, and balloons.
• the active compounds can also be in micro-encapsulated form, if appropriate, with one or more of the above-mentioned excipients.
• Liquid dosage forms for oral administration include pharmaceutically acceptable emulsions, solutions, suspensions, syrups and elixirs.
• the liquid dosage forms may include inert diluents commonly used in the art such as, for example, water or other solvents, solubilizing agents and emulsifiers including ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1 ,3-butylene glycol, dimethyl formamide, oils (in particular, cottonseed, groundnut, corn, germ, olive, castor, and sesame oils), glycerol, tetrahydrofurfuryl alcohol, polyethylene glycols and fatty acid esters of sorbitan, and mixtures thereof.
• inert diluents commonly used in the art such as, for example, water or other solvents, solubilizing agents and emulsifiers
• the oral compositions can also include adjuvants including wetting agents, emulsifying and suspending agents, sweetening, flavoring, and perfuming agents.
• Suspensions in addition to the active compounds, may include suspending agents such as, for example, ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar-agar, and tragacanth, and mixtures thereof.
• suspending agents such as, for example, ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar-agar, and tragacanth, and mixtures thereof.
• Topical administration includes administration to the skin including surfaces of the eye.
• Compositions for topical use on the skin also include ointments, creams, lotions, and gels.
• a further form of topical administration is to the eye, as for the treatment of immune-mediated conditions of the eye including autoimmune diseases, allergic or inflammatory conditions, and corneal transplants.
• the compound of the invention is delivered in a pharmaceutically acceptable ophthalmic vehicle, such that the compound is maintained in contact with the ocular surface for a sufficient time period to allow the compound to penetrate the corneal and internal regions of the eye, as for example the anterior chamber, posterior chamber, vitreous body, aqueous humor, vitreous humor, cornea, iris/cilary, lens, choroid/retina and sclera.
• a pharmaceutically acceptable ophthalmic vehicle may, for example, be an ointment, vegetable oil or an encapsulating material.
• compositions for mucosal administration may be prepared as a dry powder which may be pressurized or non- pressurized.
• the active ingredient in finely divided form may be used in admixture with a larger-sized pharmaceutically acceptable inert carrier comprising particles having a size, for example, of up to 100 micrometers in diameter.
• suitable inert carriers include sugars including lactose.
• at least 95% by weight of the particles of the active ingredient have an effective particle size in the range of 0.01 to 10 micrometers.
• rectal or vaginal transmucosal administration formulations include suppositories or retention enemas which can be prepared by mixing the compounds of this invention with suitable non-irritating excipients or carriers including cocoa butter, polyethylene glycol or a suppository wax which are solid at room temperature but liquid at body temperature and therefore melt in the rectum or vaginal cavity and release the active compound.
• suitable non-irritating excipients or carriers including cocoa butter, polyethylene glycol or a suppository wax which are solid at room temperature but liquid at body temperature and therefore melt in the rectum or vaginal cavity and release the active compound.
• the composition may be pressurized and include a compressed gas, including nitrogen or a liquefied gas propellant.
• the liquefied propellant medium and indeed the total composition is such that the active ingredient does not dissolve therein to any substantial extent.
• the pressurized composition may also include a surface active agent.
• the surface active agent may be a liquid or solid non-ionic surface active agent or may be a solid anionic surface active agent. In other embodiments, the use of the solid anionic surface active agent is in the form of a sodium salt.
• liposomes are generally derived from phospholipids or other lipid substances. Liposomes are formed by mono- or multi-lamellar hydrated liquid crystals that are dispersed in an aqueous medium. Any non-toxic, physiologically acceptable and metabolizable lipid capable of forming liposomes can be used.
• Composition embodiments in liposome form can include, in addition to a compound of the invention, stabilizers, preservatives, excipients, and the like.
• Lipids in embodiments are the phospholipids and the phosphatidyl cholines (lecithins), both natural and synthetic. Methods to form liposomes are known in the art. See, for example, Prescott, Ed., Methods in Cell Biology. Volume XIV, Academic Press, New York, N.Y. (I976), p. 33 et seq.
• immunosuppressant agents within the scope of this invention include, but are not limited to, IMURAN® azathioprine sodium, brequinar sodium, SPANIDIN® gusperimus trihydrochloride (also known as deoxyspergualin), mizoribine (also known as bredinin), CELLCEPT® mycophenolate mofetil, NEORAL® Cylosporin A (also marketed as different formulation of Cyclosporin A under the trademark SANDIMMUNE®), PROGRAF® tacrolimus (also known as FK-506), sirolimus and RAPAMUNE®, everolimus, leflunomide (also known as HWA- 486), glucocorticoids, including prednisolone and its derivatives, antibody therapies including orthoclone (OKT3) and Zenapax®, leukemia therapies, and antithymyocyte globul
• the compounds of this invention may be prepared by a variety of synthetic routes. A representative procedure is shown in Scheme 1.
• Example 1 A A solution of Example 1 A in isopropyl acetate (0.3 mL) was treated sequentially with diisopropylethylamine (87 mL, 0.5 mmol) and 1 H-tetrazole (35 mg, 0.5 mmol), and thereafter stirred for 18 hours. This mixture was partitioned between water (10 mL) and ether (10 mL). The organics were washed with brine (10 mL) and dried (Na2SO4).
• Example 1B Collection of the slower moving band from the chromatography column using the hexane:acetone (1 :1 ) mobile phase in Example 1B provided the designated compound.
• AUC Area under the curve
• Example 1 Example 2 and the internal standard were determined using the Sciex MacQuanTM software.
• Calibration curves were derived from peak area ratio (parent drug/internal standard) of the spiked blood standards using least squares linear regression of the ratio versus the theoretical concentration. The methods were linear for both compounds over the range of the standard curve (correlation > 0.99) with an estimated quantitation limit of 0.1 ng/mL.
• the blood concentration data were submitted to multi-exponential curve fitting using CSTRIP to obtain estimates of pharmacokinetic parameters.
• the estimated parameters were further defined using NONLIN84.
• the area under the blood concentration-time curve from 0 to t hours (last measurable blood concentration time point) after dosing (AUC-o-t) was calculated using the linear trapezoidal rule for the blood-time profiles.
• the residual area extrapolated to infinity determined as the final measured blood concentration (C t ) divided by the terminal elimination rate constant ( ⁇ ), and added to AUC 0-t to produce the total area under the curve (AUCo-t).
• Example 1 and Example 2 had a surprisingly substantially shorter terminal elimination half-life (ti/ 2 ) when compared to rapamycin.
• ti/ 2 substantially shorter terminal elimination half-life
• the purpose of this example was to determine the effects of a rapamycin analog on neointimal formation in porcine coronary arteries including stents.
• This example illustrates that the rapamycin analog zotarolimus, when compounded and delivered from the Biocompatibles BiodiviYsio PC Coronary stent favorably affects neointimal hyperplasia and lumen size in porcine coronary arteries.
• This finding suggests that delivery of zotarolimus from a medical device may be of substantial clinical benefit if properly applied in humans by limiting neointimal hyperplasia.
• the agent zotarolimus is a rapamycin analog, described and claimed in U.S. Patent No. 6,015,815.
• the study set forth in this example was constructed to assess the ability of the rapamycin analog zotarolimus to reduce neointimal hyperplasia in a porcine coronary stent model. Efficacy of zotarolimus in this model would suggest its clinical potential for the limitation and treatment of coronary and vascular restenosis in stents following percutaneous revascularization. The domestic swine was used because this model appears to yield results comparable to other investigations seeking to limit neointimal hyperplasia in human subjects.
• Stents were implanted in two blood vessels in each pig. Pigs used in this model were generally 2-4 months old and weighed 30-40 Kg. Two coronary stents were thus implanted in each pig by visually assessing a normal stent:artery ratio of 1.1-1.2.
• pigs were given oral aspirin (325 mg daily) and continued for the remainder of their course. General anesthesia was achieved by means of intramuscular injection followed by intravenous ketamine (30 mg/kg) and xylazine (3 mg/kg). Additional medication at the time of induction included atropine (1 mg) and flocillin (1 g) administered intramuscularly. During the stenting procedure, an intraarterial bolus of 10,000 units of heparin was administered.
• the BiodivYsio stent was used with nominal vessel target size of 3.0 mm. See Figure 2. Two coronary arteries per pig were assigned at random to deployment of the stents. The stent was either a drug eluting stent (polymer plus drug stent) or a stent coated with a polymer only (polymer only stent). The stents were delivered by means of standard guide catheters and wires. The stent balloons were inflated to appropriate sizes for less than 30 seconds.
• Each pig had one polymer only stent and one polymer plus drug stent placed in separate coronary arteries, so that each pig would have one stent for drug and one for control.
• a sample size of 20 pigs total was chosen to detect a projected difference in neointimal thickness of 0.12 mm with a standard deviation of 0.15 mm, at a power of 0.95 and beta 0.05.
• Animals were euthanized at 28 days for histopathologic examination and quantification. Following removal of the heart from the perfusion pump system, the left atrial appendage was removed for access to the proximal coronary arteries. Coronary arterial segments with injuries were dissected free of the epicardium. Segments containing lesions was isolated, thereby allowing sufficient tissue to including uninvolved blood vessel at either end. The foregoing segments, each roughly 2.5 cm in length, were embedded and processed by means of standard plastic embedding techniques. The tissues were subsequently processed and stained with hematoxylin-eosin and elastic- van Gieson techniques.
• the mid-stent segment was used for measurement, analysis, and comparison. Data were also recorded (and included in the data section of this report) for proximal and distal segments.
• Table 3 shows the pigs and arteries used.
• LCX means the circumflex branch of the left coronary artery
• LAD means the left anterior descending coronary artery
• RCA means the right coronary artery.
• Table 4 shows the summary results for all data for mean injury and neointimal thickness for each stent, including proximal, mid, and distal segments. Table 4 also shows lumen size, percent stenosis, and artery size as measured by the internal elastic laminae (IEL) and external elastic laminae (EEL).
• IEL internal elastic laminae
• EEL external elastic laminae
• Table 5 shows the statistical t-test comparisons across test groups and control groups. There was a statistically significant difference in neointimal thickness, neointimal area, lumen size, and percent lumen stenosis, the drug eluting stent being clearly favored. Conversely, there were no statistically significant differences between the test group (polymer plus drug stents) and the control group (polymer only stents) for mean injury score, external elastic laminae, or internal elastic laminae areas.
• the data demonstrates that statistically significant differences exist for morphorometric measures of efficacy favoring the stent that elutes zotarolimus.
• the stent of this invention results in lower neointimal area, lower neointimal thickness, and greater lumen area.
• a stent eluting the compound zotarolimus from a polymer showed a reduction in neointimal hyperplasia in the porcine model when placed in a coronary artery.
• the purpose of this example is to determine the rate of release of the zotarolimus drug from 316L Electropolished Stainless Steel Coupons coated with a biocompatible polymer including phosphorylcholine side groups.
• the solution included zotarolimus (30.6 mg) dissolved in 100% ethanol (3.0 ml).
• the syringe was cleaned with ethanol between each application.
• the cap to the glass vial was placed on the vial loosely, thereby assuring proper ventilation.
• the coupon was allowed to dry for a minimum of 1.5 hours. Twelve (12) coupons were loaded in this way - six being used to determine the average amount of drug loaded onto the device and six being used to measure the time needed to release the drug from the devices.
• a coupon was removed from the vial and placed into 50/50 acetonitrile/0.01M phosphate buffer (pH 6.0, 5.0 ml). The coupon was placed onto a 5210 Branson sonicator for one hour. The coupon was then removed from the solution, and the solution was assayed by HPLC.
• time release studies were performed by immersing and removing the individual coupons from fresh aliquots (10.0 ml) of 0.01 M phosphate buffer at a pH of 6.0 at each of the following time intervals - 5, 15, 30 and 60 minutes. For the remaining time points of 120, 180, 240, 300, 360 minutes, volumes of 5.0 ml of buffer were used. To facilitate mixing during the drug release phase, the samples were placed onto an Eberbach shaker set at low speed. All solution aliquots were assayed by HPLC after the testing of the last sample was completed.
• a solution of zotarolimus in ethanol at a concentration of 50 mg/ml was prepared and dispensed into twelve vials. Twelve individual polymer-coated stents were placed on fixtures constructed to hold the stent in a vertical position and the stents were immersed vertically in the drug solution for five minutes. The stents and fixtures were removed from the vials and excess drug solution was blotted away by contacting the stents with an absorbent material. The stents were then allowed to dry in air for 30 minutes in an inverted vertical position.
• the stents were removed from the fixtures, and each stent was placed into 50/50 acetonitrile/phosphate buffer (pH 5.1 , 2.0 ml) and sonicated for one hour. The stents were removed from the solution and solutions were assayed for concentration of drug, which allowed calculation of the amount of drug originally on the stents. This method was independently shown to remove at least 95% of the drug from the stent coating. On average, the stents included 120 ⁇ 9 micrograms of drug.
• Zotarolimus a tetrazole analog of rapamycin, has been shown to possess anti-restenosis activity in swine coronary stent-induced injury ⁇ Touchard AG, Burke SE. Toner JL, Cromack K and Schwartz RS. Zotarolimus-eluting stents reduce experimental coronary artery neointimal hyperplasia after 4 weeks. Eur Heart J. 27: 988-993, 2006). Delivered from the Biocompatibles Bio ⁇ f/VYs/o PC Coronary Stents in Porcine Coronary Arteries, Technical Report, Mayo Clinic and Foundation, Rochester, MN) and rat balloon angioplasty (Gregory, C.
• Doses were administered as IV bolus over 3 minutes, with 8 subjects. Four subjects received zotarolimus and 4 subjects received placebo in each dose group. Blood was sampled for 168 hours and concentrations of zotarolimus measured using LC-MS/MS with a LOQ of 0.20 ng/mL
• Safety was evaluated based on adverse event, physical examination, vital signs, ECG, injection site and laboratory tests assessments.
• Pharmacokinetic parameter values of zotarolimus were estimated using noncompartmental methods. These parameters included: concentration at 5- minutes zotarolimus post-dose (Cs), dose-normalized C5, elimination rate constant ( ⁇ ), half-life (ti/2), the area under the blood concentration vs. time curve from time 0 to time of the last measurable concentration (AUCrj-last). dose-normalized AUCrj-last. the area under the blood concentration vs. time curve extrapolated to infinite time (AUCrj-inf). dose-normalized AUCrj-jnf. total clearance (CL), and volume of distribution (Vd ⁇ ).
• AUCrj-last/Dose 0.25 ⁇ 0.06 0.26 ⁇ 0.05 0.29 ⁇ 0.06 0.30 ⁇ 0.03 0.27 ⁇ 0.02
• ANCOVA covariance
• Subjects were classified by dose level, and body weight was a covariate.
• the variables analyzed included ⁇ , Vd ⁇ , dose-normalized C5, and logarithms of dose-normalized AUCrj-iast and dose-normalized AUCrj-inf-
• the primary test of the hypothesis of invariance with dose was a test on dose-level effects with good power for a monotonic function of dose.
• the highest and lowest dose levels were compared within the framework of the ANCOVA.
• Mean elimination half-life of zotarolimus ranged from 26.0 to 40.2 hours over the studied dose range.
• the mean clearance and volume of distribution ranged from 2.90 to 3.55 L/h and 113 to 202 L, respectively.
• the observed departure from linear kinetics for/? and, to a significant extent, for Vd ⁇ was due to an overestimation of ⁇ for the 100 ⁇ g dose group.
• Phase 1 multiple-escalating dose, double-blind, placebo-controlled, randomized study. Seventy-two subjects equally divided in 3 once-daily (QD) regimens (200, 400 or 800 ⁇ g QD with 16 active and 8 placebo per regimen) were administered a 60-minute QD IV infusion of zotarolimus for 14 consecutive days. Blood samples were collected over 24 hours following the first dose, before dosing on days 10, 11, 12, 13, and for 168 hours following Day 14 dose. Urine samples were collected over 24 hours on days 1 , 14, 16, 18 and 20. Blood and urine zotarolimus concentrations were determined using a validated LC/MS/MS method. Pharmacokinetic parameters were determined by compartmental analysis. All Day-AUC 0- oo (area under blood concentration- time curve from time 0 to infinity including all 14 doses) was calculated. Dose and time-linearity and achievement of steady-state were evaluated. Fraction of drug eliminated in urine was determined.
• QD once-daily
• Subjects were randomized at two different sites to three groups (Groups I, Il and III) as shown in Table 13. Within each group, subjects were equally divided at the two study sites with each site enrolling 12 subjects (zotarolimus, eight subjects; placebo four subjects). The dosing scheme within each dose group is presented below:
• Subject 2112 prematurely discontinued the study; subject withdrew consent on Study Day 19.
• Subjects received, under fasting conditions, a single 60-minute daily (QD) intravenous infusion of 200, 400, or 800 ⁇ g of zotarolimus or a matching intravenous infusion of placebo for Groups I, Il and III, respectively on Study Days 1 through 14.
• the drug was administered via a syringe pump connected to a y-site device, which also infused 125-150 mL of 5% aqueous dextrose solution (D5W) over 60 minutes.
• the groups were dosed sequentially with at least 7 days separating the last dose of the previous group and the first dose of the next group during which time safety data from the previous group was analyzed. Dose escalation was dependent on the safety analysis of the lower dose group.
• the optimal model for each individual was used to predict the individual's concentration-time profile over a 14-day period to estimate the chronic exposure over the study duration, i.e. C max and All Day- AUCrj-oo(Area under the predicted blood concentration-time profile from time 0 to infinity taking into account all 14 doses in the study).
• Zotarolimus blood concentration-time data for all subjects were described by a three compartment open model with first order elimination.
• the mean blood concentrations for zotarolimus for Day 1 , Day 14 and Days 1 through 14 are presented in Figure 7.
• the mean ⁇ SD of pharmacokinetic parameters of zotarolimus are presented in Table 14.
• the model adequately described the data on Day 1 as well as Day 14 and in between as exemplified in 1 Figure 9 (example of mean observed and predicted blood concentration versus time plots upon fitting 800 ⁇ g QD dose group data).
• the excellent fit of the observed zotarolimus concentration-time data over Days 1 through 14 by a 3-compartment model that assumes linear kinetics indicates that zotarolimus exhibits time invariant clearance.
• the median C max for the 200, 400 and 800 ⁇ g QD dose groups was 11.4, 22.1 and 38.9 ng/mL, respectively.
• Zotarolimus pharmacokinetics were dose proportional and time invariant when administered intravenously for 14 consecutive days, over the studied dose regimens.
• Steady state for QD dosing of zotarolimus was reached by Day 10, the day on which the first trough samples were measured.
• Renal excretion is not a major route of elimination for zotarolimus as approximately 0.1 % of the dose was excreted as unchanged drug in the urine per day.
• Zotarolimus is generally well tolerated when given in multiple doses of 200, 400, and 800 ⁇ g for 14 consecutive days.
• glucocorticoids in modification of restenosis after percutaneous transluminal coronary angioplasty, Am J Cardiol, 60, 3, 1987, 56B-60B ⁇ .
• Activation of immune cells following PTCA results in cytokine/chemokine production and the recruitment of circulating monocytes to the vascular wall.
• Three important cytokines, produced by monocytes are tumor necrosis factor ⁇ (TNF ⁇ ), monocyte chemoattractant protein 1 (MCP-1 ), and interleukin 6 (IL-6). They have been shown to increase following PTCA and increased levelsof MCP-1 and IL-6 are associated with an increased incidence of restenosis ⁇ Y. Hojo, U. Ikeda, T. Katsuki, O.
• Tumor necrosis factor ⁇ is a pro-inflammatory cytokine produced by monocytes and tissue macrophages, cell types which have been implicated in the pathophysiology of restenosis (Moreno PR, Behap VH, Lopez-Cuellar J, Newell JB, McMellon C, Gold HK, Palacios IF, Fuster V, Fallon JT. Macrophage infiltration predicts restenosis after coronary intervention in patients with unstable angina.
• TNF ⁇ levels have been shown to be increased in humans with in-stent restenosis and levels of this cytokine are increased following angioplasty (Kozinski M, Krzewina-Kowalska A, Kubica J, Zbikowska- Gotz M, Dymek G, Piasecki R, Sukiennik A, Grzesk G, Bogdan M, Chojnicki M, Dziedziczko A, Sypniewska G.
• Percutaneous coronary intervention triggers a systemic inflammatory response in patients treated for in-stent restenosis - comparison with stable and unstable angina: Inflammation Research: 54: 2005:187-93).
• Anti-TNF ⁇ antibodies loaded onto a stent have been shown to reduce PCNA, a marker of cell proliferation in human saphenous vein cultures suggesting that blocking TNF ⁇ effects may result in the reduction of neointimal hyperplasia (Javed Q, Swanson N, Vohra H, Thurston H, Gershlick AH.; Tumor necrosis factor-alpha antibody eluting stents reduce vascular smooth muscle cell proliferation in saphenous vein organ culture. Exp MoI Path, 73(2): 2002: 104-11 ). Furthermore, increasing levels of TNF ⁇ can activate cytokine production by vascular smooth muscle and endothelial cells and this may lead to a sustained inflammatory response in the vascular wall.
• the glucocorticosteriod dexamethasone has potent anti-inflammatory effects on a number of cell types.
• Dexamethasone has been proposed as an a ⁇ ti-restenotic agent and is currently used on the Dexamet drug-eluting stent (commercially available in Europe from Abbott Vascular lnc.(check) ⁇ D. W. Muller, G. Golomb, D. Gordon and R. J. Levy, Site-specific dexamethasone delivery for the prevention of neointimal thickening after vascular stent implantation, Coron Artery Dis, 5, 5, 1994, 435-42 ⁇ .
• the effects of the immunosuppressants zotarolimus and sirolimus on the production of these important cytokines by human monocytes were not previously known.
• the second drug is a member of the group consisting of small molecules and biologies that reduce inflammatory cytokine activity.
• the second drug includes an anti-TNF alpha therapies consisting of the group adalimumab, anti-MCP-1 therapies and CCR2 receptor antagonists, anti-IL-18 therapies, anti-IL-1 therapies, and their salts, esters, prodrugs, and derivatives or any combination thereof.
• cytokine production by human coronary artery smooth muscle and endothelial cells following TNF ⁇ treatment was determined by measuring interleukine-8 (IL-8), MCP-1 and IL-6 production.
• IL-8 interleukine-8
• MCP-1 MCP-1
• IL-6 IL-6
• Human monocytes (Cambrex, East Rutherford NJ) were seeded into 96- well microplates (60,000 cells/well), cultured for 48 hours at 37 0 C, and then stimulated with bacterial lipopolysaccharide (LPS, 25 or 100 ng/ml) for 24 hours in the presence and absence of test compounds in culture media. After 24 hours, the supernatants were carefully collected and TNF ⁇ , IL-6 and MCP-1 levels determined by ELISA. Primary cultures of human coronary artery endothelial and smooth muscle cells were obtained from Cambrex and maintained as described by the vendor.
• LPS bacterial lipopolysaccharide
• hCaSMC 5000 cells/well
• hCaEC 7500 cells/well
• the cells were incubated for 24 hours and the supernatants carefully removed and frozen until measurement. Cytokine levels were measured in the supernatants by sandwich ELISA.
• Figure 10 shows that dexamethasone, zotarolimus and rapamycin all dose-dependently inhibit MCP-1 production by human monocytes in vitro.
• zotarolimus and rapamycin are much more potent and efficacious in this effect than dexamethasone.
• dexamethasone potently blocks the production of TNF ⁇ and IL-6 and these effects are not demonstrated by either zotarolimus or rapamycin ( Figures 10 and 11).
• the only agent demonstrating activity was dexamethasone which dose-dependently inhibits cytokine production.
• Dexamethasone blocks hCaSMC MCP-1 production by 57.2%, IL-6 by 65.7% and IL-8 by 68.4%.
• the data for all three cell types are summarized in Table 15. None of the agents tested inhibit cytokine production by hCaEC by 50% compared to controls. Since the blockade of the production of all three cytokines, (TNF ⁇ , MCP-1 and IL-6) is a beneficial anti-inflammatory effect in the prevention of restenosis, these data support the combined use of zotarolimus and dexamethasone.
• Dexamethasone has been proposed as an anti-restenotic agent and is currently used on the Dexamet drug-eluting stent (commercially available in Europe from Abbott Vascular Devices). Dexamethasone has previously been shown to be a potent hCaSMC, but not hCaEC, antiproliferative agent, (Li L, Burke, SE, Chen, Y-CJ. Comparison of drugs in inhibiting human smooth muscle and endothelial cell proliferation.: Abbott Laboratories Corporate Technology Exchange Poster Presentations; October 27, 2003: R. Voisard, U. Seitzer, R. Baur, P. C. Dartsch, H. Osterhues, M. Hoher and V.
• in vitro assays which specifically measure the antiproliferative activity of candidate anti- restenotic compounds on human coronary artery smooth muscle and endothelial cells should predict potential anti-restenotic activity in vivo.
• the tritium incorporation assay is an accurate and sensitive method used in the art to determine cell number and proliferation.
• Compounds or combinations of compounds which attenuate growth factor-mediated human coronary artery smooth muscle cell (hCaSMC) proliferation, as measured by the tritium incorporation assay in vitro, are candidate anti-restenotic agents. This assay was employed to determine if agents which demonstrate antiproliferative activity alone also demonstrate similar activity in combination.
• agents which demonstrate low potency antiproliferative activity may block the activity of more potent antiproliferative agents when administered in combination.
• the attenuation of zotarolimus's antiproliferative activity by tacrolimus is a clear example of this effect ( Figure 12).
• tacrolimus (“T") blocked the antiproliferative activity of zotarolimus in hCaSMC.
• Tacrolimus (10OnM) increased the IC50 of zotarolimus and the presence of tacrolimus (250 nM or greater) completely blocked the activity of zotarolimus (4nM).
• Both zotarolimus and tacrolimus bind the common receptor FKBP-12, although binding of each affects distinct signaling pathways.
• Dexamethasone suppresses the synthesis of key proteins required for cell division in some cell types and is a potent anti-inflammatory (Voisard R 1 Seitzer U, Baur R, et al. Corticosteroid agents inhibit proliferation of smooth muscle cells from human atherosclerotic arteries in vitro, lnt J Cardiol. Mar 1 1994; 43(3):257-267; N. Baghdassarian, A. Peiretti, E. Devaux, P. A. Bryon and M. French, Involvement of p27Kip1 in the G1- and S/G2-phase lengthening mediated by glucocorticoids in normal human lymphocytes, Cell Growth Differ, 10, 6, 1999, 405-12).
• Zotarolimus like rapamycin, blocks cyclin-dependent kinase via mTOR inhibition and inhibits cell cycle progression at the G1-S phase (S. O. Marx, T. Jayaraman, L. O. Go and A. R. Marks, Rapamycin-FKBP inhibits cell cycle regulators of proliferation in vascular smooth muscle cells, Circ Res, 76, 3, 1995, 412-7; Sehgal S. N., Rapamune (RAPA, rapamycin, sirolimus): mechanism of action immunosuppressive effect results from blockade of signal transduction and inhibition of cell cycle progression. CHn Biochem. JuI 1998; 31 (5):335-340; S. N.
• Sehgal, Sirolimus its discovery, biological properties, and mechanism of action, Transplant Proc, 35, 3 Suppl, 2003, 7S-14S).
• dexamethasone attenuated or augmented the antiproliferative activity of zotarolimus on hCaSMC
• the effect of these agents alone and in combination on growth factor induced proliferation was determined. Since re-endothelialization of vascular lesions is considered beneficial, the antiproliferative effects of both agents on hCaEC were assessed alone and in combination. Data were analyzed for interactions (additivity) using an isobologram approach and a combination index analysis as described below.
• the cells were replenished with 200 ⁇ l supplemented medium in the absence or presence of drugs at the desired concentrations.
• DMSO was maintained at a final concentration of 0.1% in all wells.
• 25 ⁇ l (1 ⁇ Ci/well) of 3 H-thymidine (Amersham Biosciences) were added to each well.
• the cells were incubated at 37 0 C for 16-18 hours to allow incorporation of 3 H-thymidine into newly synthesized DNA and the cells harvested onto 96-well plates containing bonded glass fiber filters using a cell harvester (Harvester 9600, TOMTEC).
• the filter plates were air dried overnight and MicroScint-20 (25 ⁇ l) was added to each filter well and the plates were counted using a TopCount microplate scintillation counter. Controls included medium only, starved cells and cells in complete medium. Drug activity was established by determining the inhibition of 3 H-thymidine incorporation into newly synthesized DNA relative to cells grown in complete medium.
• the x-axis represents the concentration of the drug being varied.
• the x-axis represents the concentration of the drug being varied.
• Each graph contains a dexamethasone alone curve and a zotarolimus alone curve.
• the set of curves in each graph is generated by adding dexamethasone at a fixed concentration (1 , 5, 10 or 25 nM) to various concentrations of zotarolimus (0, 0.04, 0.08, 0.8, 4, 8, 40 nM).
• Each curve represents the dose-response of zotarolimus (whose concentration is given on the x-axis) in the presence of the fixed concentration of dexamethasone (given in the legend). Note that in hCaEC higher fixed concentrations of dexamethasone were used (1 , 10, 100, 100O nM).
• X is the logarithm of concentration.
• Y is the response
• Cl values reflect the summation of effects of the combinations assuming each drug was acting in accordance with its own potency. Equation 2 describes predicted effects for the combination of two mutually nonexclusive compounds. If each drug contributes to the combined effect in accordance to its own dose-dependent fractional occupancy, then the Cl is equal to 1. Since Cl is dependent on the level of effect observed, Cl was determined at several effect levels using multiple drug combinations. Cl values were plotted as a function of the effect level (or fa) at which they were calculated. Cl values, similar to the isobologram analysis are effect level dependent and vary as the level of effect changes therefore it is important to consider effect level in comparing Cl values. The accuracy of Cl values are, in turn dependent on the accuracy of the concentration values used in their calculation.
• the isobologram analysis was performed at various effect levels to determine if the combination of zotarolimus and dexamethasone has additive activity in inhibiting cell proliferation.
• the combination index analysis shows similar results but all effect levels can be presented in one figure.
• the isobologram and combination index analyses both show that the combination of zotarolimus and dexamethasone block proliferation and that this effect is similar to that predicted by summing the effects of each single agent since Cl values are near one at the half-maximal effect level. No combination analyses were performed on the data from hCaEC since dexamethasone does not demonstrate activity in this cell type.
• Dexamethasone blocks hCaSMC proliferation but does not affect hCaEC proliferation. Furthermore, since re-endothelialization of the injured vascular wall is considered beneficial in the prevention of restenosis, these data support the use of dexamethasone as an anti-restenotic agent.
• coated stents were prepared. These were 3.0 mm X 15 mm 316L electropolished stainless steel stents. Each clean stent was spray coated using a filtered 20-mg/mL solution of phosphoryl choline polymer PC-1036 (product of Biocompatibles Ltd., Farnham, Surrey, UK) in ethanol. The stents were initially air dried and then cured at 7O 0 C for 16 hours. They were then sent for gamma irradiation at ⁇ 25KGy. [0264] II. Loading the Stent with Drugs of Interest
• All drug-eluting stents were made from Abbott's proprietary TriMaxx construct 15mm X 3.0mm stents, and all catheters were Medtronic (Minneapolis, MN) OTW, 15mm x 3.0 mm. The numbers manufactured for each combination provided sufficient numbers for accelerated elution, drug load content, impurity profile, and animal efficacy testing.
• the stents were weighed before loading with the drug solution. All stents were spray loaded to their targeted drug contents from solutions containing the appropriate drug(s) and PC1036 in ethanol in a 91 :9 ratio.
• stents were prepared at 10//g/mm of each drug. 10ug/mm zotarolimus alone was loaded on single drug stents. Once loaded, all stents were dried in open vials for 30 minutes in an oven set at 4O 0 C and weighed to determine drug loads. The drug-loaded stents were then overcoated with 5/yg/mm of PC1036 by spraying with a 10mg/ml polymer solution in ethanol.
• the stents were cured in an oven at 7O 0 C for two hours before weighing to determine overcoat weight.
• the stents were assembled onto catheters, crimped onto the balloon. The stents were then visually inspected for coating and physical defects.
• Each stent/catheter was inserted into a packaging hoop and then a Tyvek pouch. The pouch was sealed with a Vertrod Impulse Heat sealer. A stent identification label was placed in the bottom corner on the front side of the pouch, outside of the sealed area containing the product. The product was then placed in white boxes labelled with the product details and shipped for EtO sterilisation.
• the product was packaged in foil pouches containing sachets of oxygen scavenger and desiccant.
• the pouches were labelled with the stent identification number and product details.
• the pouches were sealed whilst flushing with nitrogen.
• a solubilizing agent was needed because the drugs have very low water solubility.
• the dissolution medium was buffered to minimize the degradation of "-olimus" drugs that happens at pHs above 6. Buffering at pH 4 solves this problem. Since these drugs have minimum dissociation at these pH ranges, pH has little impact on elution rate.
• Samples were pulled from the dissolution bath at selected time intervals using a syringe sampler fitted with only Teflon, stainless steel or glass surfaces. Aliquots were collected after 15 min, 30 min, 1 hr, 2 hr, 4 hr, 6 hr, 8 hr, 12 hr, 18 hr and 24 hr. The samples are assayed for zotarolimus and dexamethasone concentration via HPLC. Data are expressed as drug eluted in micrograms and mean percent eluted.
• Figures 15, 16, and 17 illustrate the accelerated elution rate of stents loaded with zotarolimus and Dexamethasone at 10 ug/mm each onto a stent with a 5 ug/mm topcoat of the polymer PC-1036 as detailed above.
• Figure 16 (% eluted drug) portrays the data in Figure 15 normalized by the total drug determined on the stent after final stent extract. As can be seen, 100% of both drugs are recovered from the stent coatings. Total drug recovered is in excellent agreement with the drug load predicted by stent weight uptake during the drug loading process. This data along with drug potency and related substances testing on stents from the same batch indicate that the drugs are stable in the polymer coating when manufactured as outlined above. The small error bars (representing the standard deviations) shows that the dual drug elution stents can be manufactured with reproducible elution kinetics.
• Example 11 Testing for neointimal hyperplasia and endothelialization after stent implantation
• This test was used to determine the dual drug effect on neointimal hyperplasia and endothelialization.
• the test exploits the art-accepted porcine coronary overstretch model (Schwartz, R.S., Restenosis and the proportional neointimal response to coronary artery injury: results in a porcine model. J Am Coll Cardiol. Feb 1992;19(2):267-274) and is usually conducted for approximately 2-8 weeks.
• experimental construct includes at least a stent control that resembles the experimental stent in every way except for the change of a single variable, including therapeutic substances or polymer.
• two major coronary arteries may be implanted with one test stent each (Cypher ® and Taxus ® ), and the third major coronary artery is implanted with a control ZoMaxxTM stent in each pig. Additional examples include the implantation of three TriMaxx ® control stents, one in each major coronary artery. The responses to these control stents can be compared with those obtained from the ZoMaxxTM, Cypher ® and Taxus ® stents implanted in separate animals.
• Stents are implanted using standard techniques. At the conclusion of the study, animals are euthanized, and the hearts are removed, washed and fixed using standard histological preservation techniques (including formalin, formaldehyde, etc.). Stented vessels are excised, then infiltrated and embedded in a suitable medium for sectioning, including methylmethacrylate (MMA), paraffin, or cryomedia. All blocks containing stented vessels are sectioned so that informative sections are obtained; for example, three, in-stent sections and two control sections.
• MMA methylmethacrylate
• Serial thin sections (approximately 5 ⁇ m) are usually taken at each level and stained to visualize the cells and tissues (e.g., hematoxylin and eosin (HE) and Masson's Verhoeff Elastin (MVE)). Sections are evaluated and scored using an image analysis system or other art accepted methods of morphological data collection and quantification. The data are scored for neointimal area, neointimal thickness, and percent-area stenosis.
• HE hematoxylin and eosin
• MVE Masson's Verhoeff Elastin
• a porcine coronary overstretch model study (Schwartz, R.S., Restenosis and the proportional neointimal response to coronary artery injury: results in a porcine model. J Am Coll Cardiol. Feb 1992;19(2):267-274) was conducted to examine neointimal formation following stent implantation for 28 days. The study evaluated a number of drug-eluting stents randomized vs. control ZoMaxxTM drug-containing polymer coated stents. In each pig, two major coronary arteries were implanted with one test stent each, and the third major coronary artery was implanted with one ZoMaxxTM stent.
• the ZoMaxxTM stents including 10 ⁇ g/mm zotarolimus as the active pharmaceutical agent. Additionally, three pigs were implanted with three bare metal TriMaxx ® stents each (9 total stents) for comparison. For the purposes of this disclosure, five types of stents were compared: 1 ) ZoMaxxTM stents (3.0 x 15 mm) containing 10 meg zotarolimus/mm; 2) commercially available sirolimus-polymer coated Cypher® (3.0 x 13 mm) stents including 8.5 mcg/mm sirolimus (as defined in Cordis FDA presentation); 3) commercially available paclitaxel-polymer coated Taxus ® (3.0 x 16 mm) stents including 6.8 mcg/mm paclitaxel (calculated); 4) stents coated with a combination of zotarolimus and dexamethasone (3.0 x 15 mm coated with
• Stents were implanted with a balloon/artery ratio of 1.30 as determined conventionally by quantitative coronary angiography. [0286] There were no cardiac or stent-related mortalities in the study. After 28 days, animals were euthanized, and the hearts were removed and perfusion fixed at ⁇ 100 mmHg with lactated Ringer's solution until cleared of blood followed by 10% neutral buffered formalin. Stented vessels were excised then infiltrated and embedded in methylmethacrylate (MMA). All blocks containing stented vessels were sectioned so that three in-stent sections plus two control sections were taken.
• MMA methylmethacrylate
• ZoMaxxTM, Cypher®, and Taxus® stents had equivalent reductions in formation of neointima, as determined by conventional morphometric measures, compared to TriMaxx® stents.
• Stents including the zotarolimus/dexamethasone combination also showed a significant reduction in neointimal hyperplasia versus the TriMaxx® stents.
• zotarolimus/dexamethasone combination stents (“Zot/Dex 10/10") also showed a further improvement in reduction in neointima versus ZoMaxxTM zotarolimus- polymer coated, Cypher® sirolimus-polymer coated, and Taxus® paclitaxel- polymer coated stents.
• Table 17 summarizes the improvements obtained with ZoMaxxTM polymer-coated and zotarolimus/dexamethasone combination drug stents versus TriMaxx® stents as a control.
• the zotarolimus/dexamethasone combination drug-eluting stent gave an average reduction in neointimal formation of 49.3% when compared to TriMaxx ® non-drug eluting stents.
• the additional dramatic reduction in neointimal hyperplasia was 22.6, 25.4, and 25.2%, respectively (Table 18).
• the therapeutic amount of a 'rolimus drug includes zotarolimus or everolimus and is at least 1 ⁇ g/mm stent.
• the second drug is dexamethasone and the therapeutic amount is at least 0.5 ⁇ g/mm stent.
• Figures 21 through 24 demonstrate the remarkable difference between our results with zotarolimus and dexamethasone and previously published results with sirolimus and dexamethasone.
• Suziki, T, et al. Stent-based delivery of sirolimus reduces neointimal formation in a porcine coronary model. Circulation. 2001 ; 104:1188-1193, Falotico R., U.S. Patent Application 2003/0216699; Table 6.0
• the previous study showed no benefit between the combination stents and the single drug-eluting stents.
• ACS acute coronary syndrome
• PCI percutaneous intervention
• obesity is often associated with a proinflammatory state and endothelial dysfunction. Both conditions are known to be independent predictors of early restenosis after coronary stent placement.
• CRP monocyte chemoattractant protein
• Plasma IL-6 and tumor necrosis factor-alpha are inflammatory cytokines that are also elevated in the obese patient, and in type 2 diabetics.
• elevation of high-sensitivity CRP, IL-6 or serum vascular cell adhesion molecule-1 (VCAM-1) have been associated with increased mortality in patients with coronary artery diseases (Roffi and Topol, Eur. Heart J. 25: 190 - 198, 2004). Since it has been shown that neointimal formation, a hallmark of the restenotic process, is accentuated by inflammation, the use of stents which deliver anti-inflammatory agents to the local vessel environment would be expected to have clear utility in diabetic patients.
• Disruption of an atheromatous plaque is central to the initiation of an acute coronary syndrome (Grech and Ramsdale, Br. Med. J., 326: 1259 - 1260, 2003). Plaque rupture may be induced by increased concentrations of matrix metalloproteinases secreted by foam cells, leading to plaque instability and ultimate rupture of the thin fibrous cap which overlies the developing lesion.
• tissue factor which is expressed on the surface of foam cells, activates coagulation factor VII, which leads to the formation of thrombin. Generation of this protein leads to platelet activation and aggregation, as well as the conversion of fibrinogen to fibrin, and the clear formation of thrombus.
• the stents described herein will be deployed in patients who are diagnosed with ischemic heart disease due to stenotic lesions in coronary arteries and in subsets of the clinical population at higher risk for recurrent coronary disease and other adverse clinical events.
• Other targets for intervention include peripheral vascular diseases including stenosis in the superficial femoral arteries, renal arteries, iliacs, and vessels below the knee.
• Target vessels for interventional procedures will be reached using percutaneous vascular access via either the femoral or radial artery, and a guiding catheter will be inserted into the vessel. The target lesion will then be crossed with a guidewire, and the balloon catheter will be inserted either over the wire or using a rapid exchange system.
• the physician will determine the appropriate size of the stent to be implanted by online quantitative coronary angiography (QCA) or by visual estimate.
• QCA quantitative coronary angiography
• the stent will be deployed using appropriate pressure as indicated by the compliance of the stent, and a postprocedure angiogram can then be obtained.
• the patient When the procedure is completed, the patient will be regularly monitored for angina status and for the existence of any adverse events. The need for repeat procedures will also be assessed.
• antiproliferative activity of the first drug reduces formation of neointima by at least 25% versus a non-drug eluting stent in a porcine coronary injury model with 30% overstretch.
• the antiproliferative effect of the first drug complements the antiproliferative effect of the second drug and reduces formation of neointima by at least 30% versus non-drug eluting stents in a porcine injury model with 30% overstretch.
• the drugs have a combination index less than or equal to 10.
• the system further includes a ratio of the therapeutic amount of the first drug to the therapeutic amount of the second drug of 1 :10 to 10:1 ratio.
• the pharmaceutical composition for reducing neointimal hyperplasia is administered locally, and includes zotarolimus or everolimus and dexamethasone, wherein the zotarolimus or everolimus and the dexamethasone are in a ratio of between about 10:1 to about 1 :10.
• the pharmaceutical composition for reducing neointimal hyperplasia is administered locally, and includes at least one olimus drug and at least one glucocorticosteriod, and wherein the olimus drug(s) and the glucocorticosteriod (s) are in a ratio of between about 10:1 to about 1 :10. Furthermore, endothelialization is accelerated relative to a single drug eluting stent.
• a receptor for the immunosuppressant FK506 is a cis-trans peptidyl-prolyl isomerase.
• RAFT1 a mammalian protein that binds to FKBP12 in a rapamycin-dependent fashion and is homologous to yeast TORs. Ce//.
• Endothelin-1 is an autocrine/paracrine growth factor for human cancer cell lines. J CHn Invest. 87:1867-71.
• a cytosolic binding protein for the immunosuppressant FK506 has peptidyl-prolyl isomerase activity but is distinct from cyclophilin. Nature. 341 :755-7.

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